A nurse is caring for a mother who delivered vaginally 2 hours ago.Select the 4 findings the nurse should report to the provider.
Fundus midline and firm at the umbilicus.
Moderate lochia rubra with no clots.
Constant trickle of blood at the vagina.
Hemoglobin level.
Heart rate.
Correct Answer : C,D,E
Choice A rationale
A fundus midline and firm at the umbilicus is a normal postpartum finding and does not require reporting. It indicates that the uterus is contracting as expected to prevent postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra without clots is expected in the immediate postpartum period and does not need to be reported. It is part of normal postpartum bleeding as the uterus sheds its lining.
Choice C rationale
A constant trickle of blood at the vagina postpartum could indicate a laceration or retained placental fragments and should be reported to the provider for further evaluation and management.
Choice D rationale
Hemoglobin levels can provide important information about the mother's blood loss during delivery. A low hemoglobin level could indicate significant blood loss and necessitates reporting.
Choice E rationale
An abnormal heart rate in a postpartum mother could be indicative of complications such as hemorrhage or infection and should be reported to the provider for further assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Keeping the baby's bassinet away from fans is good practice to avoid drafts that could make the baby cold. Maintaining a stable environment is important for newborns to help regulate their body temperature effectively.
Choice B rationale
Checking the baby's temperature rectally every 3 hours is unnecessary and potentially harmful. Rectal temperature checks are invasive and not typically needed unless directed by a healthcare provider. Axillary temperature is safer and more commonly recommended.
Choice C rationale
Keeping the baby's head covered can help maintain body temperature, especially in cooler environments. Newborns can lose heat quickly through their heads, so this practice is beneficial to keep them warm.
Choice D rationale
Placing the baby on the stomach and covering with a warm blanket is not recommended for sleeping due to the risk of sudden infant death syndrome (SIDS). Babies should be placed on their backs to sleep to reduce this risk. .
Correct Answer is B
Explanation
Choice A rationale
If the client and the newborn are both Rh positive, Rh immunoglobulin is not necessary because there is no Rh incompatibility.
Choice B rationale
Rh immunoglobulin is administered when the mother is Rh negative and the newborn is Rh positive to prevent the mother's immune system from developing antibodies against Rh-positive blood.
Choice C rationale
If the client is Rh positive and the newborn is Rh negative, Rh immunoglobulin is not needed because Rh incompatibility does not occur in this scenario.
Choice D rationale
If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, so Rh immunoglobulin is not needed.
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